Archive for October, 2009

Distribution- Day 14

Projects in progress for the Distribution rotation so far:

1. Dispensary Workflow

2. Seasonal Influenza Vaccination Procedures

3. Pharmacy checklist for Change in Stability for Refrigerated Drugs : Who to Communicate Changes to

4. Study Protocol- implemention proposal at SPH pharmacy

5. Solving Incident Reports

6. Creating Pre-printed Orders

This week, we concentrated most of our time on learning the workflow of the IV room. This rotation has given me a more wholesome picture of how a drug comes from wardstock, all the way to administration at the patient’s bedside. The system is indeed quite complicated.

Lesson from Incident Report Problem Solving:
Sometimes minor misses become major problems.

Lesson from Pharmacy checklist for Change in Stability for Refrigerated Drugs : Who to Communicate Changes to:
The layout/format of the final product is just as important as the final content itself. Excel can be your best friend.

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Distribution- Day 12

We spent most of the morning learning more about the runnings of the IV room.  Haley and I read over the latex allergy protocol in the morning.

Home IV drug batching checking + TPN 3-in-1 checking as well with Johanna.

We also spent some time each interpreting a different patient’s vancomycin level. After sifting through the information, we summarized the results in a note form.
Things to include in the note/assessment of vanco level:

  • indication
  • current dosing
  • when drug was started/stopped
  • when was last dose
  • dose drawn on time/appropriately
  • last dose given on time
  • compliance/ missed dose
  • target level
  • patient status: wbc, creatinine
  • plan: continue with drug and redo level in one week

I found it helpful to be able to contact the nurse at transitional care about this; however, it would probably have been more convenient if we can read through the chart myself.

FMI:

  • Max 5ml for IM injection
  • max 2ml for sc injection

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Distribution- Day 11

Shadowed IV technician and pharmacist today.

They introduced us to the workflow for the IV room.

I also did some checking for TPN and chemo drugs.

In the afternoon, I met up with Mara, who is the pharmacist in charge of research/studies at SPH. She introduced me to the types of studies/protocols that are being conducted at the hospital and explained what we did from the pharmacy perspective. Haley and I will be working on how a study protocol can be implemented at the pharmacy in terms of blinding, randomization, preparation,etc.

Special Access Drug: non-marketed drugs, Practioners treating patients with serious or life-threatening conditions request Special Access in cases where conventional therapies have failed, are unavailable or are unsuitable.
example: cisapride was pulled off the market due to side effects

Study drug: drug that is being tested in clinical study

Phases of drug studies:
Phase 1: adverse effects
Phase 2: dosing
Phase 3: compare drug to gold standard

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More Art- stuff

DSC03436

DSC03435

DSC03434

DSC03433

DSC03432

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Distribution- Day 10

TPN/ CHEMO IV intro day.

Important link for Chemo protocol:
http://www.bccancer.bc.ca/HPI/ChemotherapyProtocols/default.htm

Important link for lymphoma and myeloma protocols that are often found in SPH patients:
http://www.bccancer.bc.ca/HPI/ChemotherapyProtocols/Lymphoma/default.htm

SPH does not have oncologists, so the majority of the chemo IV orders is from hematologist.

Practice chart review with Ivy today. It looks like we still have some tweaking to do.

Last but not least, I presented the ” Art in Hospital- SPH Pharmacy” initiative at the acute operations meeting today. The next step is to send out an email to the staff and to put together a committee to implement these ideas. Some ideas include: mural, tile art, posting artwork from staff/patients, etc. Nevertheless, the main obstacle may ultimately be the budget. The problem being that there is no budget…..well, we’ll see what happens. I am optimistic that something good will still come out of it.

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Distribution- Day 9

Current project with Barb:

Check-List
Refrigerated Drugs: Who to notify when stability information changes
Products Services Coordinator Set up regional guidelines on how medications should be stored and their stability?
AUD Manager Liaise with AUD staff
Purchaser Alert dispensary coordiantor of changes, assess current stock and expected new drug arrival or backorder duration as a result of stability changes
Distribution Coordinator Change crashcart checklist as necessary, palm pilot update
Medication Use Manager PDTM update, find/clarify stability of new product, asses for changes in frequency of wastage, memo/email to all staff (ward/RN/MD/pharmacists) regarding stability change, +/- why, initiate Centricity catalogue and amoutn to preserve to purchaser, update pharmacy bulletin
CIVA Coordinator (for all IV meds) Update stability column of refrigerated drug list
Dispensary Coordinator ( for all other meds) establish a criteria for current and future use of non- CIVA meds, add drug warning boxes for new changes, liaise with nursing staff and other external stakeholders, liaise with MSJ
Residential Care Coordinator Liaise information to residential care, including Youville, HF, etc.
Dispensary Supervisor centricity pre-printed order updates, disseminate information to all dispensary staff through weekly updates, safety huddles, etc
Main Dispensary
Ambulatory pharmacy
IS Coordinator Labeling update
Secretary pharmweb update for refrigerated drugs list
All technicians
All pharmacists
Clinical nurse leader Disseminate information to all nursing staff on ward, check expiry date prior to admin??
Medication Safety Pharmacist assess for changes to pre-printed sheets if necessary
Physicians affected by that particular medication if drug is used regularly or ward dependent

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Distribution- Day 8

I met Barb today.

She introduced me to a book, which I finished just now.

Who moved my cheese?

It’s a very insightful book that I’m very grateful that Barb introduced me to. It was a very easy read and reading always come easier in a story form, It’s usually more meaningful too.

Who moved my cheese?

The Big Ideal

Cheese is a metaphor for what you want to have in life – whether it is a good job, a loving relationship, money, or spiritual peace of mind. Cheese is what we think will make us happy, and when circumstances take it away, different people deal with change in different ways. Four characters in this delightful parable represent parts of ourselves whenever we are confronted with change.

The Maze
Four characters live in a maze and look for cheese to nourish them and make them happy. The maze is where you spend time looking for what you want. It may be the organization you work in, the relationships you have in your life, or the community you live in.

Parts of All of Us
Two of the characters named Sniff and Scurry are mice. They represent parts of us that are simple and instinctive. Hem and Haw are the little people, representing those complex parts of us as human beings. Sometimes we are like Sniff, who anticipates change early by sniffing it out, or Scurry, who quickly scurries into action and adapts. Maybe we are more like Hem, who denies change and resists it out of fear, or Haw, who learns to adapt in time when he sees something better. Whatever part of us we choose, we all share the common need to find our way in the maze of life and succeed in changing times.

Grand Summary

Change Happens
They Keep Moving The Cheese
Anticipate Change
Get Ready For The Cheese To Move
Monitor Change
Smell The Cheese Often So You Know When It Is Getting Old
Adapt To Change Quickly
The Quicker You Let Go Of Old Cheese, The Sooner You Can Enjoy New Cheese
Change
Move With The Cheese
Enjoy Change!
Savor The Adventure And Enjoy The Taste Of New Cheese!
Be Ready To Change Quickly And Enjoy It Again & Again
They Keep Moving The Cheese.

Things that stuck out at me:
“What would you do if you weren’t afraid?”

It’s a very simple question, but I found it really hard to answer. What would I do if I weren’t afraid? First of all, I think that I would alot of stupid things, but I would probably try harder to help others. I would try harder to go out of my way to help people. I don’t think that I’m trying hard enough at the moment.


I think that this book is very appropriate at this time, especially as we are facing so much change in our profession and within out region. Our cheese is moving. Our job now is to move with the cheese.


The forward of the book talks alot about how the story has changed many people’s lives. I must admit that this intrigued me, so I continued reading. After finishing  the book, I find that I must learn to take everything with a grain of salt. First of all, I don’t believe that we should always blindly accept any type of change. In this way, I am similar to Hem in the book and NOBODY wants to be Hem from the book. This leads into my second point, which is that people are motivated to change because of the book ….and this is because of fear, which is what the book advocate you NOT to do. The book tells you to let go of your fear. After reading the book, I think that many readers are afraid to be portrayed as Hem and this fear drives people to change. It’s not as motivating if you think of this way; hence, I have decided to interpret book with a clean slate in mind.


I want to believe that the author told this story with good intention in mind.


I want to believe that this book reflects how I should devote myself in committing to the profession. I don’t like to mention it as “my” profession because I do not take sole ownership for it. I often refer to it as “the” profession because I interpret it as a whole that we all share. If I think of it this way, it not about just moving myself, it’s about moving together. With the many changes helping to the profession and the region, I believe that commitment to the profession is being able to adapt to this change in order to better serve our patients. It’s hard to be committed to change, but it is inevitable.


But if we choose to move together as a profession at the same time, it might not be so hard to adapt to.It’s like when you are riding in a moving car and there are other cars driving in the lanes beside you. You are moving, but it is not as evident to you when you compare yourself to the other cars; whereas if you are a pedestrian standing by the sidewalk, the change is clear.

I want to be committed to this changing profession.

” When you stop being afraid, you feel good.”

move with the cheese…..and enjoy it


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Distribution- Day 7

Hayley and I went over our workflow recommendations to Jeremy today. We also had some discussion about whether the paperless system has decreased frequency of errors.

Eric and I did our presentation for lytes during the academic half day today.

The presentation went well. I think that the latter section about the cases was more helpful for everyone. The cases provided a good overview about all the material that we had previously covered during the ppt. Eric was a very good presenter. He went at a very good pace and asked many thought provoking questions that led to constructive discussions. This is some thing I should work on.

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Distribution- Day 6

Continuing with workflow assessment:

5s
The concept of the 5S’s is to look at the spaces and resources that are being used and design them so that they are efficient, tidy and easy to access. This often reduces space, inventory and time requirements.

Sort
The first stage of 5S is getting rid of unneeded items, to organize the work area, leaving only the tools and materials necessary to perform daily activities. This will result in better communication between workers and, therefore, increased productivity.
Set in order / Straighten
This step involves the orderly arrangement of necessary equipment and supplies so they are easy to use and accessible to find, eliminating waste in production and other activities.
Shine
‘Shine’ focuses on maintenance and “mess prevention.” This gives a safer work area allowing problem areas to be identified more easily. By incorporating ‘shining’ into daily routines, this reduces wastage on valuable staff time.
Standardize
The fourth stage of 5S involves creating a consistent approach for carrying out tasks and procedures. Orderliness is the core of “standardization” and is maintained by Visual Controls. Some useful strategies includes the use of signboard, painting strategy, color-coding strategy and shadow boarding.
Sustain
This last stage of 5S is the discipline and commitment of all other stages. Without “sustaining”, your workplace can easily revert back to being dirty and chaotic. That is why it is so crucial for your team to be empowered to improve and maintain their workplace. When employees take pride in their work and workplace it can lead to greater job satisfaction and higher productivity.

Spaghetti Diagram

This is a tool that illustrates the movement of a person or supplies in order to perform a task. What it does is show where waste is created by having processes that do not create continuous flow. By using a visual aid to map movement it is possible to see what is happening in the process and to see where improvements can be made. Often it is hard to recognize and quantify waste caused by unnecessary movement and the spaghetti diagram is a tool that can be used to clearly illustrate this.

Below are two Spaghetti diagrams for the same process, one of a Current State and one of a Future State. Here it is clearly shown the amount of transportation currently required for travel to Surgical Day Care. By reviewing the Current State diagram it is possible to come up with a more efficient way to perform this process as illustrated by the Future State Map. The outcomes are the same but the time and resources (i.e. waste) is reduced.

 

Kaizen

Kaizens are often used by the Workflow Improvement Team as a means of pulling a group involved in a process together to look at the current state a process is in and come up with ideas for improvement. 

Kaizen events have specific objectives to:

  • 5S the area
  • Reduce wait time
  • Improve throughput at workstations

Three Components of Kaizens:

  • Quick and crude is better than slow and elegant
  • Find the low hanging fruit
  • Take no action and nothing will happen

 Kaizens…

  • Start with taking a look at the actual place of work
  • Require a bias for action
  • Must have clear benefits

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Distribution- Day 5

Hayley and I started on the dispensary workflow flowchart today. Based on the flowchart, we started brainstorming some potential ideas for improvement. We are finding it hard to find areas of improvement. Perhaps, it’s because the system has been refined so many times that it gets harder and harder to improve upon it.

We also worked on some trouble/shoot exercises together as a group.

Interesting video from a friend: ( This reminds me that we can always improve upon some thing…regardless of what it is and maybe potentially, even making it fun. I hope that our dispensary workflow project will make a difference for the pharmacy staff and the people we serve)

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